Surgical fastener system

ABSTRACT

A fastener system for utilizing an H-shaped fastener which is composed of a pair of shaft members having a diameter of approximately 1 mm that are interconnected by a bridge shaft resiliently joined to the shaft members to form the H-shape. The shaft members have sufficient columnar resistence to bending to permit a shaft member to be compressively inserted into body tissue. A fixation tool carries the fastener for injection into body tissue and has a housing with a needle tip of approximately 5 mm in length. The needle tip has a longitudinally extending slot into which the bridge shaft of the H-shaped fastener member is captively held by interference fit. A setting rod is extendible through the needle tip and bears against a shaft of the H-shaped fastener such that an external force applied to the setting rod will be transmitted to the fastener to drive it into the body tissue.

This application is a division application of application Ser. No.07/681,685 filed Apr. 5, 1991, now U.S. Pat. No. 5,203,864.

FIELD OF THE INVENTION

This invention relates primarily to a fastener system and method for usein laparoscopic surgical repair of inguinal herniation and for use insuturing body tissue to body tissue.

BACKGROUND OF THE INVENTION

Surgical treatment of inguinal herniae traditionally involved theremoval or excision of the peritoneal sac and the strengthening of theweakened inguinal canal by performing a herniotomy, hernioplasty, orherniorrhaphy; in the case of inguinal herniae, the surgical techniqueentailed the excision of the femoral sac and either closing the marginsof the internal ring or excluding it from continuity with the abdominalcavity. In some of these cases simple suture could not successfullyclose the hernia defect and a relaxing incision was required in therectus sheath to bring the tissues together and allow the defect to beclosed without tension. Where however, the patient's groin had beendestroyed by repeated herniation and surgery, a mesh prosthesis made ofpolypropylene was used as a substitute for the relaxing incision.

Insertion of a polypropylene mesh prosthesis for the repair of inquinalherniae required a transverse incision through the abdominal wall inorder to introduce the mesh into the preperitoneal space andsubsequently to suture the anterior femoral sheeth, and the iliac fasciaand encompassed the floor of the inguinal canal extending from the pubictubercle laterally to the femoral vein along the superior pubic ramus,superiorly to the transversus arch, and laterally to beyond the internalinguinal ring. The sutures to Cooper's ligament, the anterior femoralsheath and the iliac fascia required the knots to be tied posterially ofthe abdominal wall. Sutures were also required to be passed through therectus muscle and the rectus sheath and tied anteriorly. Cephaledsutures were also necessary which incorporated a folded edge of thepolyprophylene mesh and also closed the transverse incision which wasused for access to the preperitoneal space.

SUMMARY OF THE INVENTION

There is, therefore, provided according to the present invention, asurgical fastener system for laparoscopically fixing a mesh prosthesisto body tissue for the laparoscopic repair of inguinal herniation or forother types of repair requiring the fixing of body tissue to body tissuenon-laparoscopically. The present invention is directed to auni-directional dart-type fastener in one embodiment where the dartfastener is composed of a shaft member having a diameter ofapproximately 1 mm and having a radially extending head or disk at oneend and an anchor member angularly inclined to the shaft at its otherend. The anchor member is resiliently collapsible radially to the shaftand biased in an open position which permits the anchor member tocollapse radially during the dart's penetration of body tissue andpermits it to be captively held uni-directionally within the bodyfascia. The dart fastener may be made of materials such as ofpolypropylene, stainless steel, or polydioxanone suture (PDS®) which isa trademark of Johnson and Johnson. In order to set the dart fastenerlaparoscopically, a dart fixation tool is provided which may beintroduced into the space between the peritoneum and posterior abdominalwall through a trocar having an internal diameter of approximately 5 mm.

The dart fixation tool is composed of a cylindrical housing which has acartridge rotationally carried at its distal end. The cartridge has aseries of cylindrical chambers for carrying an individual dart fastenerand are equally spaced radially and located adjacent to the periphery ofthe cartridge in a manner similar to the cartridge chambers of arevolver. A drive shaft extends longitudinally through the housing torotate the cartridge and index each chamber into alignment with asetting rod which also extends longitudinally through the housing. Thesetting rod is slideably mounted in the housing and capable of extendingthrough the aligned chamber of the cartridge by a thrust or externalforce applied to the setting rod by the surgeon. Each chamber isloadable with a single dart fastener which is captively held in thechamber by a leaf spring; by pushing on the setting rod the surgeonforces the rod to extend through the chamber thereby overcoming theresistance of the leaf spring and ejecting the dart fastener from thechamber. The setting rod is thereafter retracted from the chamber andthe cartridge is rotated by the surgeon to bring the adjacent succeedingchamber into alignment with the longitudinal bore containing the settingrod.

Another embodiment of the dart fixation tool provides a tool whichcaptively carries a single dart fastener by interference fit or by leafspring retention located adjacent the distal end of the tool housing. Acavity or passage extends axially through the housing and a plungerwhich extends through the cavity transmits the external thrust forceapplied by the surgeon at the proximate end of the tool to the fastenerto eject the fastener from the tool.

In another embodiment of the invention, an H-shaped fixation surgicalfastener is provided for attaching polypropylene mesh to body tissue.The fastener is composed of a pair of shaft members having a diameter ofapproximately 1 mm which are interconnected by a bridge shaft which isresiliently joined to the shaft members to form an H-shaped member whichis internally biased to retain the H configuration. To accommodatedriving the fastener into the resistence of body tissue, the shaftmembers have sufficient columnar resistance to bending to permit a shaftmember to be compressively inserted into body tissue. The H-shapedfastener may be made of materials such as polypropylene, stainlesssteel, or polydioxanone suture (PDS®) which is a trademark of Johnsonand Johnson.

The H-shaped fastener is introduced into the preperitoneal operativespace by a fixation tool composed of a housing which has a longitudinalaxis, a proximate and distal end, and an axially extending cavity orpassage through the housing. At its distal end, the housing contains aneedle member which has an axial length of approximately 5 mm. Anaxially extending conduit extends through the needle member andcommunicates with the housing cavity. The needle member has alongitudinally extending slot which communicates with the conduit. Atthe distal end of the needle tip the slot is open which allows thebridge shaft of the H-shaped fastener member to extend through the slotwhen either shaft member of the H-shaped fastener is inserted into theneedle tip of the housing. To set the fastener, a setting rod extendsthrough the cavity of the housing and is slideably mounted to thehousing so that the distal end of the setting rod may be selectivelyextended through the needle member conduit. The H-shaped fastener iscaptively held in the needle tip by interference fit and introduced intothe preperitoneal operative region by inserting the fixation toolthrough a trocar.

To insert the H-shaped fastener into body tissue, the needle tip of thetool is manipulated to pass through an interstice of the mesh prosthesisand the surgeon then applies an external force to the setting rod tothrust the rod which in turn applies a compressive force against thedriven shaft of the captively held H-type fastener thereby ejecting thefastener from the needle tip while pressing the driven shaft into thebody tissue. The material of the H-shaped fastener has the property of asufficient modulus of resilience to restore the H-shape such that theundriven shaft of the H-shaped fastener will bear against the mesh whilethe driven shaft will be biased toward a position within the fasciaessentially parallel to the undriven shaft with the bridge memberextending through an interstice of the mesh.

A method for laparoscopically attaching a mesh prosthesis to body tissueto repair inguinal herniation utilizing the fastener system of thisinvention provides for forming a retroperitoneal space by the injectionof carbon dioxide gas through a Verress needle positioned in thesuprapubic region, separating the peritoneum from the posteriorabdominal wall, inserting a laparoscope into the retroperitoneal space,inserting a mesh prosthesis into the space and positioning the mesh tooverlay the pelvis, and fixing the mesh to the posterior abdominal wallby sufficiently inserting a fastener through a mesh interstice so as tobear against the mesh and penetrate into the body tissue.

Thus, a fastener system is provided to repair inquinal herniaelaparoscopically without the necessity of suturing the mesh by tyingknots anteriorly or posterially of the abdominal wall. The mesh isintroduced laparoscopically into the preperitoneal space and simplyfastened to Cooper's ligament, the iliac fascia, and the abdominal wallto repair the inquinal or femoral hernia. Although the fastener systemof this invention has a particular use to repair inguinal herniae, itmay also be utilized for non-laparoscopic repairs to body tissue.

BRIEF DESCRIPTION OF THE DRAWINGS

These and other features and advantages will become appreciated as thesame become better understood with reference to the followingspecification, claims and drawings wherein:

FIG. 1 is a front view of the dart fastener according to the presentinvention.

FIG. 2 is a top view of FIG. 1.

FIG. 3 is another embodiment of the dart fastener of the presentinvention.

FIG. 4 is a top view of FIG. 3.

FIG. 5 is a front view of another embodiment of the dart fastener of thepresent invention.

FIG. 6 is a top view of FIG. 5.

FIG. 7 is a front view of the setting tool of the present invention,illustrating the loaded cartridge at the distal end of the tool.

FIG. 8 is a cross-sectional view along line 8A--8A of FIG. 7illustrating another embodiment of setting tool.

FIG. 8A is a cross-sectional view along the line 8A--8A of FIG. 7illustrating one embodiment of the setting tool of the presentinvention.

FIG. 9 is an illustration of the dart fastener being inserted throughthe mesh prosthesis and into body tissue.

FIG. 10 is illustrates the dart fastener fixing the mesh prosthesis tobody tissue.

FIG. 11 is a cross-sectional view of another embodiment of my presentinvention for setting a dart-like fastener.

FIG. 12 is a posterior view of the left inguinal region of the humanbody.

FIG. 13 illustrates a preperitoneal placement and fixation of a meshprosthesis in the region depicted in FIG. 12.

FIG. 14 is a partial cross-sectional view of my invention of a fixationtool for inserting an H-shaped fixation fastener through body tissue.

FIG. 15 illustrates the H-shaped fastener of my invention positioned forinsertion through an interstice of a mesh prosthesis and into bodytissue.

FIG. 16 illustrates the H-shaped fastener of my invention afterinsertion into body tissue and before entering the fascia.

FIG. 17 illustrates the H-type fixation fastener of my invention afterbeing seated in body tissue.

DETAILED DESCRIPTION

Laparoscopically guided preperitoneal hernia repair as performed in thepresent invention requires that the surgeon insufflate theintraperitoneal cavity with carbon dioxide gas until 15-18 mm Hgpressure. When the pressure is achieved, a 10 mm trocar is inserted intothe peritoneal cavity through which a 10 mm 30-degree angle laparoscopeis inserted and a TV camera attached. After a general abdominalexploration, the camera is pointed toward the pelvis. In the suprapubiclocation, a Verress needle (not shown) for gas injection is theninserted beneath the posterior abdominal wall but not through theperitoneum and carbon dixoide gas is thereafter injected through theneedle into the space between the peritoneum and posterior abdominalwall until a small cavity is created. The needle is then removed and a10 mm trocar is inserted into the cavity or retroperitoneal spacebetween the peritoneum and posterial abdominal wall to accommodate theinsertion of a reducer having a blunt probe (not shown) which is used tosweep the peritoneum from the underside of the abdominal wall.

The sweeping of the peritoneum from the abdominal wall is donebilaterally. If the right inguinal region is approached first forsweeping, the peritoneum is swept from the underside of the aponeuroticsling, more inferiorily the underside of the direct floor transversalisfascia and then the inguinal ligament, and then the femoral canal andthe iliopubic tract which is the superior pubic ramus fascia. Usingblunt dissection, the peritoneum is taken off the inguinal cord as itenters the peritoneal cavity. The same procedure is then followed on theleft side of the pelvis. Two 5 mm trocars (not shown) are then placedbetween the lower abdominal wall and the peritoneum in the left andright midclavicular lines respectively in the pelvis and into thecavity. A 5 mm laparoscope is then inserted through either of the 5 mmtrocars, depending upon the location of the inguinal hernia to providefor observation of the region. A sheet of plastic mesh preferablypolypropylene is now introduced into the cavity between the peritoneumand posterior abdominal wall through the 10 mm trocar which had beenoriginally placed in the midline in the suprapubic position. After themesh is introduced into the cavity, a 10 mm laparoscope with 30-degreeangle lens is then inserted into the 10 mm site, and two graspers areinserted, one through each of the 5 mm trocars to manipulate thepolypropylene mesh sheet within the cavity such that the mesh overlaysthe pelvis.

FIG. 12 is an illustration of a posterior view of the left inguinalregion showing Cooper's ligament femoral ring 2, transversus abdominismuscle 3, posterior inguinal wall 4, conjoint tendon 5, the posteriorabdominal wall 6, and the iliac fascia 7 before attachment of the meshprosthesis. The right inguinal region is a mirror image of the left.

FIG. 13 illustrates the laparoscopic placement of a mesh prostheses 10which is fastened to Cooper's ligament 1 by a dart fastener 11 of thisinvention. Similarly, other portions of the mesh prosthesis 10 arefastened to the posterior abdominal wall 6 and the iliac fascia 7.Although FIG. 13 illustrates the mesh fastened to the left, the mesh mayextend across to the right region thereby covering the entire region. Inthe preferred method of repairing inquinal herniation, the mesh isattached bilaterally. Referring now to FIGS. 1 through 6, the dart typefasteners 11 of the fastening system of this invention are shown.

FIG. 1 is a side view illustration of dart fastener 11 and FIG. 2 is atop view. The dart fastener is preferably made of polypropylene.However, the dart may be made of stainless steel, or polydioxanonesuture (PDS®) which is a registered trademark of Johnson and Johnson. Ascan be seen in FIG. 1, dart fastener 11 has a shaft member 12 and alonditudinal axis 13. The shaft member 12 is integrally formed with thedisc or head 14 at the second end 15 of the dart. At the first end 17 ofthe dart fastener, shaft member 12 has a plurality of anchor members 18extending radially from the shaft at an approximate 45-degree angle withthe longitudinal axis; anchor members 18 are spaced angularly about thelongitudinal axis at equal angles.

Other embodiments of dart fastener 11 are shown in FIGS. 3 through 6 andit can be seen in FIG. 3 that dart fastener 11 is comprised of twoanchor members 18' which are spaced diametrically opposite from eachother at the first end 17 of dart fastener 11 and extend radially fromthe longitudinal axis at an angle of approximately 45-degrees. In theembodiment as shown in FIGS. 5 and 6, the dart fastener has one anchormember 18" which extends in the same manner from shaft 12 as theembodiments previously described. Anchor members 18, 18', and 18" extendresiliently from the shaft 12 such that when the anchor member iscompressed radially into shaft 12, the anchor member will be biased tospring back toward its equilibrium position. The anchor members areextended at an angle of approximately 45-degrees from the longitudinalaxis of dart fastener 11 in the preferred embodiment. However, any anglewould be appropriate less than 90° provided the dart could penetrate aninterstice of the mesh prosthesis if used for laparoscopic herniarepair. Thus, when the dart fastener is inserted into body tissue, theanchor members will radially collapse such that the anchor memberbecause of the resilience of the material will be biased to springradially outward and the dart fastener will be captively heldunidirectionally in the body fascia in much the same manner as aharpoon.

Since the dart fasteners are inserted laparoscopically into thepreperitoneal space by insertion through trocars of diameters of 5 to 10mm, the dimensions of the dart fasteners are of very small magnitudes.The diameter of shaft member 12 is preferably 1 mm with the anchormembers having a length of approximately 11/2 mm and the overall lengthof the dart fastener approximately 4 mm. The head or disc 14 of the dartfastener is preferably 3 mm in diameter and approximately 1 mm inthickness. The dart fasteners are made of a materials which arewell-tolerated by the human body such as polypropylene, stainless steel,or "PDS"® and which have the physical property of a sufficient modulusof resilience to store the elastic energy caused by the radial collapseof the anchor member.

The setting of dart fastener 11 in body tissue is shown in FIGS. 9 and10. In FIG. 9, it can be seen that mesh 10 contains numerous interstices20 through which the first end 17 of dart member 11 passes beforeentering the posterior abdominal wall 6. As can be seen in FIG. 9,anchor member 18' collapses radially as the dart fastener passes throughthe mesh 20 and into the posterior abdominal wall. Referring to FIG. 10,which illustrates the dart fastener 11 after penetrating through theabdominal wall and into the body fascia 21, upon entering fascia 21anchor members 18' are urged or biased to spring back to theirequilibrium position thereby fixing the dart fastener to the body tissueand securing the mesh 10 to the posterior abdominal wall 6.

The delivery and fixation of dart fastener 11 laparoscopically isachieved by the use of a tool which can be inserted through a trocar andthereafter manipulated by the surgeon to seat the fastener. FIG. 8illustrates the preferred embodiment of the dart fixation tool 25 ofthis invention. Dart fixation tool 25 is shown in partial cross-sectiontaken along the line 8A--8A of FIG. 7. FIG. 7 depicts a front view ofcartridge 26 which is loaded with dart fasteners 11 in a multiplicity ofperipheral chambers 27 that extend longitudinally through cartridge 26and are angularly spaced at equal intervals about the periphery of thecartridge 26. The diameter of chambers 27 is approximately equal to thediameter of the disc or head 14. To load cartridge 26, the dartfasteners 11 are inserted into the cartridge at the cartridge's distalend 28.

In the embodiment shown in FIG. 8, each chamber contains a leaf spring29 to captively hold dart fastener 11; however, in another embodiment,dart fastener 11 may be captively held may by interference fit inchamber 27 through closely held tolerances between the head or disc 14and the diameter of chamber 27. To remove a dart fastener from itscaptive chamber during the process of fixing the dart to body tissue, aplunger 30 is slideably mounted within housing 31. As shown in FIG. 8,if a force is applied to plunger 30, the head of the plunger 32 actsagainst disc 14 of dart 11 and forces the dart through the chamber byremaining in bearing contact with the head or disc 14 of dart fastener11. In this manner, the dart is fixed to human tissue and plunger 30 isthereafter retracted through chamber 27 and into the housing 31.

Handle 33 is utilized by the surgeon in both applying the force to seatthe dart fastener and for retracting plunger head 32 through the chamber27 into housing 31. As can be seen in FIG. 8, a stop 34 is provided toprevent the plunger head 32 from further retraction into housing 31. Theplunger head 32 after retraction into housing 31, is contained withinlongitudinal bore 35 of distal plug 36 which is carried by housing 31 byinterference fit and in fixed relationship to the housing. The diameterof longitudinal bore 35 is approximately the same as the diameter ofchamber 27; thus, when a chamber 27 is aligned with longitudinal bore35, the plunger 30 may be directed into and through chamber 27 by theapplication of an external force at the handle 33.

Continuing with the description of dart fixation tool 25 illustrated inFIG. 8, a drive rod 37 is carried by housing 31 and extends throughcentral bore 38 of distal plug 36. Drive rod 37 is threaded into acartridge 26 such that rotation of drive rod 37 will rotate cartridge 26with respect to housing 31. As can be seen in FIG. 8, drive rod 37 isdriven at its proximate end by a gear train comprised of bevel gear 39which is engaged by gear 40 where gear 40 in turn is carried by housing31 and connected to knurled knob 41 for rotation therewith. Thus, thesurgeon, by rotating knurled knob 41 positions cartridge 26 relative tothe housing 31 to align a chamber 27 with the longitudinal bore 35 ofdistal plug 36. To mechanically achieve this alignment, the cartridge 26carries a pair of balls 45 which are biased into engagement with distalplug 36 by springs 46. Distal plug 36 contains a series of detents 47which are located radially about the central axis of distal plug 36 andspaced equally such that chamber 27 alignment with longitudinal bore 35occurs when balls 45 are biased into the detents 47. This permits thesurgeon to index carridge 26 after seating a dart fastener by rotationof knurled knob 41, and thus align the next loaded chamber for receivingthe plunger head 32.

Another embodiment of the dart fixation tool of this invention isillustrated in FIG. 8-A. In this embodiment, driver rod 37' is attacheddirectly to knurled knob 41' to permit direct rotation of the cartridge26 without the utilization of a gear train.

FIG. 11 is still another embodiment of a fixation tool for use in thefastener system of this invention. In this embodiment of the invention,dart fixation tool 50 carries a single dart fastener 11 in longitudinalbore 51. Bore 51 extends through cylinder 52 which threads into griphead 53. Grip head 53 has an internal chamber 54 which communicates withlongitudinal bore 51 thereby providing a continuous cavity or passagethrough both grip head 53 and cylinder 52. To provide for ejection of afastener from the cavity, a plunger 55 with plunger head 56 is slideablycarried by the assembly of cylinder 52 and the grip head 53. At itsproximate end, plunger 55 is attached to thrust knob 57 to which anexternal force may be applied to move plunger 55 through longitudinalbore 51 to eject dart fastener 11 from the tool at its distal end 58. Ahelical spring 63 is held within chamber 54 in compression by bearingsurface 64 located at the proximate end of cylinder 52 and by washer 65which is mounted on plunger 55 to restore the plunger head to itsinitial position before application of the external force. A pair ofradially extending shoulder members 58 and 59 project from grip head 53to provide a counter reactive grip for the surgeon during the course ofapplying a force to thrust knob 57.

In operation the surgeon applies a continuous force by thumb pressure tothrust knob 57 which causes plunger head 56 to bear against disc 14 ofdart fastener 11. The continuous application of external force overcomesthe spring force exerted by leaf springs 61 and 62 and drives dartfastener 11 through longitudinal bore 51 and into body tissue.

Another embodiment of the fastener system of this invention is shown inFIGS. 15, 16 and 17. As can be seen in FIG. 17, a fixation fastener 70,made of a material such as polypropylene, stainless steel orpolydioxanone suture having the physical property of a sufficientmodulus of resilience to store the elastic energy caused by bending ortorsion and having the shape of an H, is composed in part by a pair ofessentially parallel cylindrically shaped shaft members 71 and 72 whichare preferably 1 mm in diameter and 4 mm in length. A bridge shaft 73having a diameter of 1 mm interconnects shafts 71 and 72 and forms anintegral joint with each of shafts 71 and 72 at its intersections. Thejoints 74 and 75 because of the resiliency of the material permit shafts71 and 72 to pivot about the joints but are biased by the resiliency ofthe material such that the shaft members and the bridge member will bebiased to return to an H-shape. Thus, fixation fastener 70 has anequilibrium position in the H-shape shown in FIG. 17 and the shaftmembers are resiliently joined together such that the internal elasticforces of the material will tend to bias the shaft members back to theequilibrium position in the event they are disturbed therefrom. To setfixation fastener 70 in body tissue, either of the shaft members 71 or72 may be driven by an external force through an interstice 76 of themesh prosthesis 77. The external force may be applied to either shaft 71or 72 by setting tool 80 which is more definitively illustrated in FIG.14.

Referring to FIG. 14, it can be seen that setting tool 80 has a housing81 with a longitudinal cylindrical cavity 82 extending axially throughthe housing along longitudinal axis 83. A needle member 84, having aninternal axially extending bore 85 communicates with cavity 82 of thehousing forming a continuous cylindrical axially extending passagethrough setting tool 80 through which plunger 86 may be extended orretracted by a member of the surgical team.

At the distal end of setting tool 80 an axially extending slot 87 isprovided which permits the setting tool to be loaded with fixationfastener 70 by extending either shaft 71 or 72 of the fixation fastenerinto the opening at the distal end 85 of needle tip 84. The bridge shaft73 of the fastener extends through the slot 87 which has a slotthickness substantially the same as the diameter of bridge shaft 73 suchthat the fastener 70 is captively held in the slot by an interferencetype fit. To drive fastener 70 into human tissue, the distal end ofsetting tool 80 is inserted into a trocar of sufficient diameter toaccommodate the diameter of the tool. By the surgeon gripping shouldermembers 88 and 89 which extend radially from the proximate end ofhousing 81, and pressing thumb disc 90, slideably mounted plunger 86within the housing 81 is forced to move axially toward the distal end 85of the tool. Thus, plunger head 91 is brought into bearing contact withshaft 71 of fixation fastener 70 as more clearly shown in FIG. 15.

Although not shown in the Figures, housing 81 of setting tool 80 mayalso be structured, for retracti on in a manner similar to the tool asillustrated in FIG. 11. Thus, by utilizing a cylinder member and griphead as shown in FIG. 11, housing 81 could be adapted to incorporate ahelical spring and washer for applying a restoring force to plunger 86after thumb disc 90 is released.

Referring now to FIG. 16, it can be seen that needle member 84 in thesetting process of fastener 70 is inserted through an interstice 76 ofthe mesh prosthesis 77 by the surgeon. By applying continuous pressureto thumb disc 90, the surgeon forces shaft 71 of the fastener into bodytissue 78; shaft 71 will thereafter under continued pressure go throughbody tissue 78 until the shaft 71 is in the fascia and bridge member 73has extended through body tissue 78 as shown in FIG. 17. The surgeonthen withdraws plunger 86 into the housing 81 and retracts setting tool80 through the trocar for reloading.

Thus, referring again to FIG. 13, and continuing with the method toattach the mesh prosthesis to the posterior abdominal wall, the mesh aspreviously described was introduced into the cavity between theperitoneum and the posterior wall through a 10 mm trocar located in themidline in the suprapubic position. A 10 mm laparoscope with a 30-degreeangle lens was then inserted through the 10 mm trocar and two graspertools used to grasp the mesh were inserted into the cavity through two 5mm trocars or sheaths which were placed in the left midclavicular andright midclavicular lines repsectively in the pelvis. The meshprosthesis is fixed to the abdominal wall by inserting dart fastener 11approximately 2 cm lateral to femoral ring 2; this is accomplished byinserting fixation tool 25 through either the right or left 5 mm trocarand holding the mesh with the grasper tool inserted through the other 5mm trocar. After the dart fastener 11 has been placed laterally of thefemoral ring by the surgeon, the mesh which is of pre-selecteddimensions may be manipulated to cover the entire pelvis bilaterallyfrom, for example, the right side of the inguinal cord across themidline to the left side of the cord. Fixation tool 25 is then insertedthrough the appropriate 5 mm trocar to set a dart fastener to fix themesh to Cooper's ligament on both the left and right sides andthereafter to the abdominal wall 6 on both the left and right sides ofthe inguinal region.

While I have shown alternative embodiments of the present invention, itis to be understood that they are subject to many modifications withoutdeparting from the scope and spirit of the claims as recited herein.

What is claimed is:
 1. A setting tool for laparoscopically inserting afastener into body tissue comprising:a) a housing having a longitudinalaxis and a proximate and distal end; b) a needle member having a centralaxis carried by said housing adjacent said distal end of said housing soas to form the distal tip of said setting tool, said needle memberhaving a conduit extending, axially therethrough and an axial open slotextending partially through the periphery of said needle member, andcommunicating with said conduit where said slot is axially bounded in adirection proximate of said distal tip and so proportioned anddimensioned to captively hold said fastener; and c) setting meansslideably carried by said housing and responsive to external force forapplying a thrust force axially within said needle member to saidfastener so as to eject said fastener from said slot and into said bodytissue.
 2. The setting tool recited in claim 1 wherein said settingmeans further comprises a plunger member adapted for axial extensionthrough said conduit, a washer mounted to said plunger member, and ahelical spring compressively bearing against said washer member and saidhousing for applying a restoring force to said plunger.
 3. The settingtool recited in claim 2 wherein said housing has an axially extendingcavity therethrough where said cavity communicates with said conduitforming an axially extending passageway.